Radiofrequency (RF) ablation of the lateral sacral plexus has been used for the treatment of sacroiliac joint pain including as an adjunct to other palliative therapies for the treatment of painful osseous metastasis. The treatment goal is targeted ablation of the dorsal lateral branches of S1-S4. Though several techniques have been described, the Simplicity III (Neurotherm, Middleton, MA) system allows for ablation to be achieved with a single RF probe by utilizing a multi-electrode curved RF probe to create a continuous ablation line across all sacral nerves. In the standard approach, there is sequential introduction of a spinal needle along the desired ablation tract for local anesthesia followed by separate placement of the ablation probe. Though fluoroscopic guidance is utilized, multiple needle passes increase the risk of complication such as bowel perforation or probe insertion through a neural foramen. It may also extend procedure time and increase radiation dose. We illustrate a technique for Simplicity III RF ablation of the dorsal sacral plexus using a modified Seldinger approach for treatment of a patient with sacroiliac joint pain due to osseous renal cell carcinoma metastasis. The desired ablation tract is initially anesthetized via a hollow micropuncture needle. The needle is then exchanged for a peelaway sheath. The RF probe is inserted through the peelaway sheath thus ensuring the probe is placed precisely along the previously anesthetized tract allowing the procedure to be completed using a single percutaneous puncture. We believe that this approach decreases the risks of bowel perforation, patient discomfort as a result of multiple percutaneous punctures, and procedure time. Key words: Simplicity 3, sacral plexus ablation, image-guided approach, modified Seldinger, chronic sacral pain, thin wall introducer needle

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Background: Vertebral augmentation (VA) techniques have changed the paradigm of treatment during the past decade and involve injection of polymethylmethacrylate (PMMA) cement directly into a compressed vertebral body. During the summer of 2009, the INVEST trial was one of 2 randomized controlled studies that reported equivalence between vertebroplasty and a control procedure. Objective: In this analysis, we sought to compare the subset of patients studied in the INVEST trial to a tertiary academic institution with respect to 2 variables: Workers compensation status and presence of advanced imaging prior to the procedure. Study Design: Retrospective review of 634 procedures. Methods: We performed a retrospective review of 634 vertebral augmentation procedures at our institution between June 2004 and August 2008, overlapping with the dataset of the INVEST trial. The primary comparison was whether patients received Workers compensation and/or advanced imaging prior to the procedure. The study was IRB approved, and in accordance with HIPAA guidelines. Results: There were 409 patients who underwent 634 procedures between June 2004 and August 2008. Among 634 procedures, only 3 included Workers compensation. Therefore, the majority of patients (> 99%) did not receive Workers compensation compared to the INVEST trial (11 – 13%). Similarly, in 629 out of 634 procedures (99.2%), patients underwent advanced imaging comprised of magnetic resonance imaging (MRI), computed tomography (CT) or bone scan. Limitations: We simply looked at 2 elements of the patient demographic in a time-matched fashion and compared it to the U.S. based INVEST trial. It is possible that despite our diligent efforts to review the data set, we have inadvertently excluded some patients, the incorporation of whom might have changed the statistics. Conclusion: We reviewed our time-matched database in terms of 2 variables we thought curious in the INVEST trial. In comparison to our practice, where advanced imaging is essentially required and Workers compensation largely not seen, these aspects of the INVEST trial’s population stood out. Key words: Spinal fractures/therapy, vertebroplasty/methods, kyphoplasty, evidence-based medicine, pain management, treatment outcome

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